PsA and the Liver (NOT drug related)

General
1

As some of you know, I have issues with health anxiety in general and have a big problem with blood test results. This makes me turn to Dr Google. I knew I shouldn't, but hey. However, sometimes something interesting pops up - and I thought this might be of interest or use.

My series of blood tests began in June 2014 when the first test was done for rheumatoid arthritis. As far as I was aware, it was clear. And so was the second later in the year. However, in January 2015, when I first saw a rheumatologist, she looked at the bloods and said, rather accusingly:

"Your liver isn't good, is it?"

"Isn't it?"

"No. You must drink a lot."

"I don't drink at all."

"Are you sure."

"I think so. Nobody has mentioned this before."

"Well, we need an ultrasound to see what's going on. This isn't good."

So, coming away scared half to death, I went to see my GP a day or two later and asked her about it. She said that the GGT element of the liver function tests had been high (over 200 - it should be 0-60), but since my medication for bipolar can affect that significantly, she said it was nothing to worry about as nothing else within my liver was affected and she wasn't concerned at all about it. Anyway, I had the ultrasound, all was clear, and that was in Feb 2015. As of September, the levels had stayed roughly the same.

Now, I have blood test results on Thursday and I'm bricking it, as usual, in case the liver has become something serious. So, while on Dr Google, I tried looking for links between GGT and PsA. It appears that there IS a link, even without medication playing a part. Here are a couple of quotes from what I found.

Serum gamma-glutamyltransferase (GGT) and alkaline phosphatase (AP) were assayed in 98 consecutive patients with rheumatoid arthritis. Twenty-three patients had increased GGT activities...The changes in these enzymes in this small series could not be related definitely to drug therapy.

In 183 in-patients with rheumatoid arthritis, the serum gamma glutamyl transferase (GGT) level was elevated in 47%...A closely similar pattern was found in 45 patients with non-rheumatoid arthritis (ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and undefined arthritis)...Hepatotoxicity could not be traced to any single drug or combination of drugs given. On the contrary, chloroquine appeared to reduce serum gamma glutamyl transferase.

Patients with diabetes, hyperthyroidism, rheumatoid arthritis, and obstructive pulmonary disease often have an increased GGT, but the reason for this elevation is unknown.

The above are from three different medical journal articles or websites. I realise some mention only RA, but others mention PsA too - I just chose clippings from the papers that seemed to say something in language we can understand! And we know that PsA often mirrors RA.

My issue here is that it seems that this link isn't necessarily recognised (or seemingly even known about) by our rheumatologists. Mine back in January 2015 certainly didn't say "this could be due to PsA," and neither have the people I have seen since. But it would make sense, since my GGT levels have remained (so far) roughly the same whether I have been on medication for the arthritis or not! Sure, the bipolar meds probably play a part in mine being a bit higher still, but I find it almost reassuring that my results thus far with the liver have not been "bad" as the first rheumy (nickname: Grotbags) called it, but probably relatively normal given the PsA.

I don't know if there are other people in the same boat with this type of thing, but thought it just might be worth bringing this to people's attention. I realise we're just the public and don't fully understand medical stuff like this, but I feel a little disconcerted that I can find probably a dozen or so medical articles online making the link between the two and yet none of my doctors have even thought that they might be connected!

Sorry if that made no sense at all. But I hope it did!

2

I know what you mean about rheumatologists not connecting dots that would seem to be connected. My rheumy hedged his bets as to whether my hip bursitis was due to PsA which seemed odd to me seeing as it's a joint problem.

However the extracts you give are about association rather than causation, which are very different things. Populations of people with chronic diseases do seem to provide quite a few associations but there must be a whole host of reasons for that including co-morbidities, lifestyle factors, long-term use of medication etc. etc. A quick bit of googling suggested to me that PsA probably isn't considered responsible for raised GGT. The only thing I've heard about the liver from my rheumy team was when the biologics nurse said that I probably had a 'psoriatic liver'. She explained that PsA patients can have sensitive livers. Like you I had a liver scan which showed my liver was fine, though that was for persistently raised ALT rather than GGT. I don't know if my GGT has ever been measured. The liver scan results did make me a happy bunny, I love hearing that something is fine!

Clearly you are someone who is inclined to delve! Me too, though I'm not systematic about it. I don't think there's a known cure for an inquiring mind but you're going to find stuff that scares you for sure, very often unnecessarily. But I'm sure you know this. One thing that I hang onto is that people with PsA were always said to have a shorter life expectancy than 100% healthy folk but the years lost amounted to about 4, which doesn't sound too disastrous to me. Recently I've noticed that we're now meant to live a normal life span. That is something I find very interesting given all our ups and downs.

3

Good morning darinfan.

Yes, liver issues are one of the recognised co-morbidities (remember a co-morbidity is the presence of one or more additional conditions co-occurring with a primary disorder). Myself, I have mild fatty liver.

I'm going to quote from a book written by the two doctors who are likely the worlds leading PsA authorities (Drs Gladman and Chandran from the Toronto Clinic): Evidence of liver dysfunction is not uncommon in patients with PsA. The most common reason for liver test abnormalities is NAFLD. NAFLD is the hepatic manifestation of the metabolic syndrome. In patients with psoriasis, NAFLD is associated with metabolic syndrome, obesity, hyperlipidaemia, and PsA. Liver function abnormalities may be compounded by treatment with methotrexate, leflunomide and occasionally anti-TNF agents.

It sounds to me like your GP is on top of it, and as you've had the ultrasound, is happy. When you have your bloods taken going forward the docs will monitor you for CHANGES to your basline 'normal' which may indicate an unhappy liver. My results fluctuate a bit and I'm try to lose weight too as that will help. But the important thing to remember with the liver is that if a med doesn't agree with you and starts to affect your liver, stopping the medication or reducing the dose, allows the liver to recover/regenerate. It is an amazing organ! I hope this is reassuring to you.

4

Looks like raised GGT can be a sign of non-alcoholic fatty liver disease (NAFLD), but that NAFLD would show up on a liver scan. It may be over-simplistic to think that a clear liver scan suggests that PsA is not currently affecting the liver, though that would seem to be the upshot of your scan result.

Perhaps 'sensitive' does apply, perhaps our livers complain quicker or more bitterly about other things .... drugs, alcohol etc.


Jules G said:

It sounds to me like your GP is on top of it, and as you've had the ultrasound, is happy.

5

I'm not going to get into the liver issue. What DOES concern me is the way that your doctor communicated this to you. Is your doctor aware of how you react to medical news? This may be just as important to deal with as actual test results.

6

I’m not going to get into liver issues either, except to say that I have fatty liver too. Of course.
But someday you will have to tell us the story of Grotbags. It’s about time we had some light entertainment around here.

7

Thanks all. I was given the all-clear at Ultrasound level regarding fatty liver and the like (and worse) - and, oddly, the GGT is the only part of the liver function tests that was/is elevated, which is why I thought it was interesting there was a link with it being possibly "normal" or "common" for this to happen with PsA and for it not to be particularly concerning. Interestingly, the only time it ever returned to normal levels was after my first batch of steroid injections in my knees, where it feel back to just under 100 in a couple of weeks (before rising again). So, perhaps there is a link with disease flare ups etc. Not sure, but an interesting link.

As for Grotbags, for those of you that don't know, she was a green evil witch on a kids programme in the UK in the 1980s. My first rheumy got the nickname because she came across so foul! After telling me I had a humped back, flat feet, bandy knees and was too pale (I did tell her I could get a spray tan if she preferred), she then went on to the liver thing mentioned earlier. It was something of a trial by fire at my first rheumy appt. I like to know what's going on and ask questions so I fully understand everything and what to expect in the future. She told me it was her job to ask questions and not mine, and that ended that conversation. In short, she made Donald Trump seem polite and subtle!

I went back to my GP after and asked her to initiate a transfer to another rheumy, which is what happened, thankfully. And I have not seen grotbags since as a patient - although she occasionally goes past while I'm in the waiting room. On her broomstick!

8

Just a quick note to this discussion. I was saying how nervous blood test results make me, and got the latest ones today. I'm pleased and relieved to say that my ESR has dropped from 107 to 47 since the last one back in September, and that the liver was all pretty much OK too. Ironically given this thread, the hospital didn't ask for GGT to be measured, but the rest of the LFTs were either in normal ranges or only very marginally out. This is great news for me, and the first concrete positive step healthwise in nearly two years. I am a happy chap!

9

Congratulations on good news! Amazing how much it can mean to hear something possative right?!

10

You have no idea! (well, you do, but you know what I mean!)

11

Just what you need! I do love a good blood test!

Here's hoping they just get better & better!